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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005860
Report Date: 03/07/2023
Date Signed: 03/07/2023 01:45:55 PM

Document Has Been Signed on 03/07/2023 01:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:MCGREGOR HOME GARFIELDFACILITY NUMBER:
347005860
ADMINISTRATOR:MARIA KATRINA SOFACILITY TYPE:
740
ADDRESS:3136 GARFIELD AVENUETELEPHONE:
(916) 692-5886
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 4DATE:
03/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:CaregiverTIME COMPLETED:
01:50 PM
NARRATIVE
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On 3/7/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management health and safety visit. LPA met with caregiver and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions and wore a surgical mask while present .
Staff were prompted by LPA to wearing masks.
LPA did a inspection of the interior of the home. The home is clean and in good repair.
Three staff are present and resident needs appear to be met.
LPA conducted a file review of 4 of 4 resident files and 3 staff files.
Facility Staff used a door stop to hold a fire door open to resident rooms hall.

Staff were told that S4 cannot currently be present in the facility.

File reviews found:
Hospice care training for R3 and R4 is not on file at the facility.
R1 and R2, who both have dementia do not have LIC 602 (physician report) or Needs and Service Plans on file dated within the last 12 months.
Staff files found a lack of current training on file. Last training on file dated from 2016. All three 1st aid certificates on file are expired in 2020.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Nina Lemence. Copy and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/07/2023 01:45 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 03/07/2023 at 01:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: MCGREGOR HOME GARFIELD
FACILITY NUMBER: 347005860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2023
Section Cited
CCR
87705(c)(5)

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Care of person's with dementia- Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually. This requirement was not based on file review found 2 of 2 residents with expired LIC 602
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Licensee will provide copies of current LIC 60s and Needs and Services plans to CCL by the POC date of 3/28/23.
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and no reappraisals on file. This posed a potential risk to residents.
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Type B
03/28/2023
Section Cited
CCR87411(c)

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Personnel Rquirements- General- (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requiremtn was not met based on file reviews that found
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Licensee will provide proof of current required training for S1-S3 to CCL by the POC date of 3/28/23
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3 of 3 staff had expired 1st aid certificates and last training on file for 2016. This poses a potential risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Maribeth Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023


LIC809 (FAS) - (06/04)
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